Name
PERITONSILLAR ABSCESS
DESCRIPTION
DETAIL
CAUSES Polymicrobial infection is the rule in peritonsillar abscess and multiple bacteria will likely be grown from cultures of drained pus. Streptococcus species are the most common pathogens. . Aerobic bacteria . Streptococcus pyogenes . Streptococcus milleri group . Haemophilus influenzae . Viridans streptococci . Neisseria species . Staphylococcus aureus . Anaerobic bacteria . Fusobacterium . Peptostreptococcus . Prevotella . Bacteroides -------------------------------------------------------------------------- DIFFERENTIAL DIAGNOSIS β’ Peritonsillar cellulitis β’ Tonsillar abscess β’ Infectious mononucleosis (EBV infection) β’ Aspiration of foreign body β’ Dental infection β’ Salivary gland infection β’ Cervical adenitis β’ Mastoiditis β’ Internal carotid artery aneurysmLABORATORY β’ Leukocytosis β’ Culture of pathogens from aspirated or drained pus to identify organism(s) IMAGING β’ Ultrasonography will show a discrete abscess cavity if present. Computed tomography (CT scanning), best performed with contrast, will also show a discrete abscess cavity. Edema of the surrounding tissues can also be seen on CT scan. DIAGNOSTIC PROCEDURES Incision and drainage of pus, via needle aspiration or an operative procedure under general anesthesia or conscious sedation.
TYPENOTES
RISK FACTORS: Prior episodes of tonsillitis, Age (young are more susceptible)GENERAL MEASURES β’ Intravenous rehydration β’ Pain control SURGICAL MEASURES Small studies indicate that rates of success are equivalent between needle aspiration and operative incision and drainage. β’ Needle aspiration with ultrasound or CT guidance β’ Operative incision and drainage when needle aspiration is too diffi cult due to trismus or lack of patient cooperation β’ Immediate tonsillectomy at the time of incision and drainage (known as quinsy tonsillectomy) has decreased in favor, due to increased risk of hemorrhage and overall low rates of abscess recurrence without tonsillectomy β’ Delayed tonsillectomy (known as interval tonsillectomy) has also fallen from favor, due to the low rates of recurrent abscess ACTIVITY As tolerated DIET No restrictions, liquid diet may be tolerated best until pain improves PATIENT EDUCATION Important to complete course of antibiotics DRUG(S) OF CHOICE Penicillin remains the standard antimicrobial therapy with initial therapy delivered parenterally. Tailor therapy to cultured pathogens as possible. If organisms other than oral Streptococci are suspected, expanded therapy may be indicated. With growing concern for beta-lactamase producing organisms, antibiotics with beta-lactamase inhibitors or cephalosporins may be preferred. If Fusobacterium or Bacteroides are implicated, additional anaerobic therapy with metronidazole may be indicated with increasing resistance to penicillin among these pathogens. . Preferred . Penicillin G 1-4 million units IV q 4 hours, OR . Benzathine Penicillin G 1.2 million units IM x 1, OR . Benzathine Penicillin G 900,000 units and Procaine Penicillin G 300,000 units IM x 1 . Alternate . Penicillin V 500 mg (25-50 mg/kg for children) tid for 10-14 days . For penicillin allergic patients, erythromycin ethyl succinate 300 to 400 mg tid OR Cephalexin 250-500 mg tid . If resistant organisms (including oral anaerobes) are suspected, add to the above oral therapy: . Metronidazole 500 mg tid-qid OR Clindamycin 150- 450 mg tid-qid . Alternatively . Amoxicillin-Clavulanate (Augmentin) 500 mg tid or 875 mg bid OR Cefuroxime 500 mg bid (or other second or third generation cephalosporin) AND metronidazole 500 mg tid-qid PATIENT MONITORING . Follow-up to ensure resolution of symptoms and tonsillar infl ammation . Lack of improvement may indicate antibiotic-resistant pathogens or residual abscess necessitating repeat drainage PREVENTION/AVOIDANCE N/A POSSIBLE COMPLICATIONS . Airway obstruction . Spread to parapharyngeal or retropharyngeal spaces . Septic jugular vein thrombosis . Brain abscess . Sepsis . Possible complications of incision and drainage: . Pulmonary aspiration of blood and pus with bronchopneumonia . Tonsillar hemorrhage . Perforation of the carotid artery EXPECTED COURSE/PROGNOSIS . Symptoms will improve rapidly after incision and drainage and appropriate antibiotics . Pain and infl ammation may persist for up to a week after treatment . Recurrent peritonsillar abscess does occur, but is rare
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
COMPLETE BLOOD COUNT, PUS CULTURE TEST, CT SCAN, ULTRA SOUND EXAM
[PERITONSILLAR ABSCESS]